Developing community-based intervention strategies and package to save newborns in Nepal.

In Nepal, the proportion of under 5 deaths that are neonatal (0-28 days) has been increasing in the last decade, due to faster declines in infant and child mortality than in neonatal mortality. This trend is likely due to a focus on maternal and child survival programs that did not adequately address newborn health needs. Policy and actions to save newborn lives resulted from increased attention to newborn deaths in 2001, culminating in the endorsement of the National Neonatal Health Strategy in 2004, a milestone that established newborn health and survival as a national priority. Operationalization of the National Neonatal Health Strategy took place in 2007 with the development of the Community-Based Newborn Care Package (CB-NCP). This paper describes how national stakeholders used global, regional and in-country research and policies to develop the CB-NCP, thus outlining key ingredients to make newborn health programming a reality in Nepal. A technical working group was constituted to review existing evidence on interventions to improve newborn survival, develop a tool to prioritize neonatal interventions, and conduct program learning visits to identify key components appropriate to the Nepal context that should be included in the Community Based Integrated Newborn Care Package. The group identified interventions based on the evidence of impact on newborn survival, potential mechanisms within the existing health system to deliver the interventions, and linkages with existing programs and different tiers of the health system. Not only was Nepal one of the first countries in south-east Asia where government adopted a national strategy to reduce neonatal deaths, but it was also one of the first to endorse a package of neonatal interventions for pilot testing and scaling up through existing community-based health systems that provide basic health services throughout the country. CB-NCP was designed to be gradually scaled up throughout the country by integration with Safe Motherhood and Child survival programs that are currently operating at scale. Under Ministry of health and Population leadership, a network of academia, professional bodies and partners developed a common vision for improving newborn health and survival, and launched district-level pilot programs to demonstrate and learn how newborn health interventions could be effectively and efficiently delivered and scaled up in Nepal.

Influence of the subfornical organ on meal-associated drinking in rats.

A lesion of the subfornical organ (SFO) may disrupt drinking after a meal of dry chow as it does drinking after intragastric administration of hypertonic saline. Food and water intakes of SFO-lesioned (SFOX) and sham-lesioned rats were measured during 90-min tests following various lengths of food deprivation. During the tests, all rats began eating before they began drinking. After 20-24 h of food deprivation, latency to begin drinking after eating had started was longer for SFOX than for sham-lesioned rats. Plasma osmolality was elevated by 2-3% in both lesion groups at 12 min, the latency for sham-lesioned rats to drink, but SFOX rats nevertheless continued eating and delayed drinking. Eating after shorter 4-h food deprivations and ad libitum feeding produced more variable drinking latencies and less consistent effects of SFO lesion. During 24 h of water deprivation, SFO lesion had no effect on the suppression of food intake and did not affect food or water intakes during the first 2 h of subsequent rehydration. These findings indicate that the SFO is involved in initiating water intake during eating and in determining drinking patterns and the amount of water ingested during a meal.

Effects of SFO lesions on salt appetite during multiple sodium depletions.

A depletion of sodium may increase sodium intake by increasing the synthesis of angiotensin (ANG) II in the blood and by stimulating ANG II receptors in the subfornical organ (SFO) of the rat. Lesions of SFO reportedly reduce these intakes. The present experiments tested the effects of SFO lesions on salt appetite after three successive depletions. After a furosemide-induced natriuresis, Long-Evans rats had free access to water- and sodium-deficient diet for 22 h. Water and 0.3 M NaCl were given for 2 h, and then the rats received regular chow, water, and 0.3 M NaCl until the next injection 5 or 7 days later. SFO lesions reduced water intake 1-2 h after each furosemide injection but not during the overnight periods. The lesions did not affect salt appetite the next day, 24-26 h after furosemide, but they did prevent the expected increase in the chronic daily 0.3 M NaCl intake after repeated depletions. The second experiment was similar to the first except that three subcutaneous injections of 100 mg/kg captopril were given at 1, 18, and 20 h after furosemide for the second depletion only. After the first depletion, the results were similar to those of the same condition of the first experiment. After the second depletion, captopril greatly reduced water intake and salt appetite in all rats including those with SFO lesions. Thus, we found that the lesion reduced chronic intake, but we did not replicate results showing large effects of SFO lesions on acute salt appetite. This residual acute appetite after SFO lesion remains dependent on the synthesis of ANG II.

Circumventricular organs and ANG II-induced salt appetite: blood pressure and connectivity.

A lesion of the subfornical organ (SFO) may reduce sodium depletion-induced salt appetite, which is largely dependent on ANG II, and yet ANG II infusions directly into SFO do not provoke salt appetite. Two experiments were designed to address this apparent contradiction. In experiment 1 sustained infusions of ANG II into SFO did not produce a sustained elevation of blood pressure, and neither a reduction of blood pressure alone with minoxidil and captopril nor a reduction of both blood pressure and volume with furosemide and captopril enhanced salt appetite. Infusions of ANG II in the organum vasculosum laminae terminalis (OVLT) did evoke salt appetite without raising blood pressure. In experiment 2 knife cuts of the afferent and efferent fibers of the rostroventral pole of the SFO abolished water intake during an infusion of ANG II into the femoral vein but failed to reduce salt appetite during an infusion of ANG II into the OVLT. We conclude that 1) hypertension does not account for the failure of infusions of ANG II in the SFO to generate salt appetite and 2) the OVLT does not depend on its connectivity with the SFO to generate salt appetite during ANG II infusions.

Effects of bile duct ligation and captopril on salt appetite and renin-aldosterone axis in rats.

A ligation of the common bile duct (BDL) produces cholestasis and hypotension and increases the daily ingestion of sodium chloride solutions in rats. Low-dose captopril (CAP) treatment also modifies the ingestion of water and sodium in naive rats, and may do so in cholestatic rats. This study examined whether the elevated ingestion of saline by Long-Evans rats after BDL is associated with increased plasma renin activity (PRA), and whether treatment with a low dose of the angiotensin converting-enzyme inhibitor CAP further exacerbates fluid intake and PRA after BDL. In these experiments water and 0.3 M saline intake and PRA and plasma aldosterone (PA) were measured in naive and CAP-treated BDL and sham-ligated rats. We found that BDL elevated rats' daily saline intake 2 weeks after the ligation procedure but had no effect on PRA. CAP (0.1 mg/mL) placed in the drinking water of some BDL rats further increased saline intake. Both PA and hematocrits tended to be reduced in BDL rats, whereas PRA was elevated in both BDL and sham-ligated rats receiving CAP in the drinking water or by gavage (0.1 mg/mL in 10 mL/kg). The data suggest that the ingestion of saline by rats can be modified by BDL and CAP administration, but that exaggerated saline intake in BDL rats is not associated with excessive renin secretion.

Drinking and blood pressure during sodium depletion or ANG II infusion in chronic cholestatic rats.

After a chronic ligation of the common bile duct (BDL), Long-Evans rats are hypotensive and have elevated saline intake during both sodium-depleted and nondepleted conditions. We tested whether BDL rats have exaggerated hypotension during sodium depletion or an elevated dipsogenic response to angiotensin II (ANG II) that might help to explain the saline intake. After 4 wk of BDL, rats were hypotensive at baseline and developed exaggerated hypotension during acute furosemide-induced diuresis. Without saline to drink, BDL rats increased water intake during depletion equal to sham-ligated rats. However, with saline solution available at 22 h after sodium depletion, the BDL rats drank more water and saline than did sham-ligated rats. This rapid intake temporarily increased their mean arterial pressure to equal that of sham-ligated rats. Intravenous infusion of ANG II induced equal drinking responses despite reduced pressor responses in the BDL rats relative to sham-ligated rats during both ad libitum and sodium-depleted conditions. Thus BDL rats have exaggerated hypotension during diuresis, and their hypotension is corrected by drinking an exaggerated volume of saline, but they do not have an increased drinking response to ANG II.

Effects of SFO lesion or captopril on drinking induced by intragastric hypertonic saline.

This study examined the hypothesis that the subfornical organ (SFO), a circumventricular organ with both osmosensitive elements and dipsogenic receptors for circulating angiotensin (ANG) II, is important for the water drinking response that follows an intragastric (ig) load of hypertonic NaCl. A 2-ml saline load was administered ig at 300, 900, or 1200 mOsm/kg to rats with sham lesions or lesions of the SFO, and intake was measured periodically for 2 h. Hypertonic loads caused sham-lesioned rats, but not SFO-lesioned rats, to drink earlier in the test or to drink more water than did the isotonic load. Inhibition of ANG II synthesis in unoperated rats with 100 mg/kg of captopril reduced water intake only during the initial 15 min after a gavage of 1200 mOsm/kg saline. Loads of 900 and 1200 mOsm/kg both increased plasma osmolality and sodium concentration by 15 min after gavage without greatly affecting hematocrit or plasma protein concentration. Thus, the SFO is important for the osmotically-induced water drinking response after acute ig administration of hypertonic saline. With the possible exception of the first 15 min, this drinking response is independent of the peripheral synthesis of ANG II.

Influence of salt intake, ANG II synthesis and SFO lesion on thirst and blood pressure during sodium depletion. Subfornical organ.

Water intake was elevated in sodium-depleted rats during a daytime salt appetite test, but other rats drank a similar amount of water when saline was not available for drinking during the test. This water intake stimulated by sodium depletion was blocked by an inhibition of angiotensin (ANG) II synthesis with a high dose of captopril (100 mg/kg, sc). Captopril did not reduce water intake by causing hypotensive shock or uremia, because water and saline intakes were increased rather than decreased after a low dose of captopril (5 mg/kg) that also reduced blood pressure and elevated blood urea nitrogen. The water intake, but not salt appetite, induced by sodium depletion was greatly reduced by a lesion of the subfornical organ (SFO) in one-bottle tests, and this was not clearly related to any effects of the lesion on blood pressure. A physiological role for ANG II in water intake induced by sodium depletion has recently been disputed, but the simplest explanation for the data remains that elevated levels of circulating ANG II bind to receptors in the SFO to generate daytime water drinking during sodium depletion.

Ethanol preference, metabolism, blood pressure, and conditioned taste aversion in experimental cholestasis.

The effect of a ligation of the common bile duct (BDL) on the chronic free-selection intake of ethanol was investigated. Rats were given a choice between water and a solution of either 6% (v/v) ethanol, 0.06% (w/v) sodium saccharin, or a mixture of both ethanol and saccharin. In different experiments, solutions were first presented either 3 weeks before surgery, about the time of surgery, or 2 weeks after surgery. Reductions in ethanol or saccharin intake were observed in BDL rats whenever the solutions were first presented either 3 weeks before or shortly after the surgery. No differences attributable to BDL were seen when ethanol solutions were first presented 2 weeks after surgery. The contingent nature of the effect suggests that the reduction results from a conditioned taste aversion rather than from differences in ethanol metabolism, sensitivity, or neurohormones such as angiotensin. The findings urge caution in the monitoring of the dietary habits of patients with a rapidly developing biliary obstruction.

Interaction of hydration and subfornical organ lesions in sodium-depletion induced salt appetite.

The authors tested whether the level of hydration after furosemide diuresis and 22 hr of sodium depletion affects the amount of water or 0.3 M NaCl solution consumed by rats with intact brains or with lesions of the subfornical organ (SFO). Rats received 2 (underhydrated) or 10 (euhydrated) ml/kg water by gavage as the only fluid input 2, 4, and 20 hr after 10 mg/kg furosemide. These hydration treatments had little or no effect on the amount of saline consumed in 2 hr by intact rats. SFO lesions reduced water intake regardless of hydration condition. Euhydrated, SFO-lesioned rats drank a normal amount of saline, but underhydrated, lesioned rats drank less saline than any other group. Thus, euhydration may facilitate salt appetite in SFO-lesioned rats, and the deficits in salt appetite noted in SFO-lesioned rats may result from deficits in water ingestion rather than from a destruction of angiotensin II receptor sites that directly provoke salt appetite.

Childhood mortality after a high dose of vitamin A in a high risk population.

OBJECTIVES: To determine whether a single high dose of vitamin A given to all children in communities with high mortality and malnutrition could affect mortality and to assess whether periodic community wide supplementation could be readily incorporated into an ongoing primary health programme. DESIGN: Opportunistic controlled trial. SETTING: Jumla district, Nepal. SUBJECTS: All children aged under 5 years; 3786 in eight subdistricts given single dose of vitamin A and 3411 in remaining eight subdistricts given no supplementation. MAIN OUTCOME MEASURES: Mortality and cause of death in the five months after supplementation. RESULTS: Risk of death for children aged 1-59 months in supplemented communities was 26% lower (relative risk 0.74, 95% confidence interval 0.55 to 0.99) than in unsupplemented communities. The reduction in mortality was greatest among children aged 6-11 months: death rate (deaths/1000 child years at risk) was 133.8 in supplemented children and 260.8 in unsupplemented children (relative risk 0.51, 0.30 to 0.89). The death rate from diarrhoea was also reduced (63.5 supplemented v 97.5 unsupplemented; relative risk 0.65, 0.44 to 0.95). The extra cost per death averted was about $11. CONCLUSION: The results support a role for Vitamin A in increasing child survival. The supplementation programme was readily integrated with the ongoing community health programme at little extra cost.

PIP: The objective of this study was to determine whether a single high dose of Vitamin A given to all children in communities with high mortality and malnutrition could affect mortality and whether periodic community-wide supplementation could be readily incorporated into an ongoing primary health program. This opportunistic controlled trial was conducted in Jumla district, Nepal and subjects included all children under age 5--3786 in 8 subdistricts were given single doses of Vitamin A and 3411 in the remaining 8 subdistricts were given no supplementation. Mortality and cause of death in the 5 months after supplementation were the main outcome measures assessed. The risk of death for children ages 1-59 months in supplemented communities was 26% lower (relative risk 0.74, 95% confidence interval 0.55-0.99) than in unsupplemented communities. The reduction in mortality was greatest among children ages 6-11 months; the death rate (deaths/1000 child-years at risk) was 133.8 in supplemented children and 260.8 in unsupplemented children (relative risk 0.51, 0.30-0.89). The death rate from diarrhea was also reduced (63.5 supplemented vs. 97.5 unsupplemented; relative risk 0.65, 0.44-0.95). The extra cost/death averted was about $11.00. These results support a role for Vitamin A in increasing child survival. The supplementation program was readily integrated with the ongoing community health program at little extra cost.

Reduction in total under-five mortality in western Nepal through community-based antimicrobial treatment of pneumonia.

Pneumonia is a leading cause of death among children world wide but those at highest risk in developing countries have limited access to clinical services; effective and low-cost alternatives are a global public health priority. We have done a controlled intervention trial among 13,404 children under five in Jumla, Nepal, which relied exclusively on indigenous community health workers to detect and treat pneumonia according to the World Health Organisation decision strategy, with a five-day home-treatment course of oral co-trimoxazole. No other health services were provided, and referral of children to hospital was not practicable. During the three-year study, 2101 deaths were recorded. The programme led to a 28% reduction in the risk of death from all causes by the third year of services (relative risk 0.72, 95% confidence interval 0.63-0.82), with a significant trend (p less than 0.02) of lower mortality with greater duration of the programme. The greatest benefit was among infants. In addition to reduction in deaths due to pneumonia, there was a significant reduction in deaths due to diarrhoea and measles, indicating that reduction in pneumonia morbidity had considerable carry-over effect. Our findings show that indigenous community workers can effectively detect and treat pneumonia, and reduce overall child mortality, even without other primary care activities.